Synopsis On 27 November 1998, while crossing between Les Escoumins and Rimouski, Quebec, in foul weather, the master of the scallop dragger BRIERMIST informed the Marine Communications and Traffic Services that he thought the hold and afterpeak were taking on water and that the pumps were not able to cope with it. At about 1500, the vessel foundered some 10 nautical miles off Rimouski. Despite the search and rescue operations, no trace of the wreck or of three of the five crew members was found. The two recovered victims had drowned. Section 3 of this report contains the Board's findings as to causes and contributing factors and other findings. In Section 4, the Board has identified safety deficiencies related to the inspection of hatch covers on small fishing vessels, the absence of automatic release mechanisms on liferafts and the absence of emergency position indicating radio beacons. The Board has issued four safety recommendations to address these safety deficiencies. The Board is concerned by the lack of safety action taken following recommendations previously issued by the Board on water level detectors, protection from hypothermia and drowning, and marine emergency duties training for fishermen, and recommendations on the same issues by the Chief Coroner as a result of this accident. Section 4 also lists the relevant safety action taken by Transport Canada, the Quebec Chief Coroner's Office and the TSB. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The BRIERMIST was a series-produced vessel built in 1981 by Gilfords Ltd. in Dartmouth, N.S., according to plans approved by the Canadian Coast Guard (CCG) in 1979. Several fishing vessels were built from the same mould. Although these vessels have reinforced polyester hulls from the same mould, a number of variants were produced for various Nova Scotia fisheries. 1.2 History of the Voyage The BRIERMIST was purchased in the spring of 1998, but because much of the summer was spent on repairs to the hydraulic system, the vessel did not begin fishing until early September. On 25 November 1998, the vessel began fishing in the St. Lawrence River in fishing area 16A near the mouth of the Saguenay River. Because fishing was good and the vessel had caught her quota, the master agreed to fish for another fisherman. There were a number of fishing days remaining in the area, so the master continued fishing despite the fall storms. The routine on board the BRIERMIST was to fish until the hold was full, and then return to port immediately to unload and sell the catch before resting. For some time, the price for fresh scallop in Rimouski had been higher than at Sept-les, Que. The master therefore sold his catch on the south shore. On November 26, after fishing, the vessel departed with a partial load of about 11 tons of scallops; the vessel had a capacity of 13 tons. After weathering a storm the previous day (46 km/h north-east winds), the vessel took shelter at the Les Escoumins pilot station wharf for the night of 27 November 1998. The next morning, the weather forecast indicated that the wind would soon turn to the north-west. According to the official weather data, at about 0900 eastern standard time (EST)[3], the strong north-east wind quickly turned to the west-north-west (44 km/h). The sea near the north shore of the river calmed, but the swell was still from the north-east. The BRIERMIST departed at 0938, and the master informed the Les Escoumins CCG Marine Communications and Traffic Services (MCTS) that he expected to arrive in Rimouski at about 1400. The distance is about 34 miles. At 1258, the estimated time of arrival was changed to 1530; the vessel was then 15.5 nautical miles (M) from Rimouski (see Appendix A). At about 1340, during a call made on a cellular telephone, the master told his agent in Rimouski that the sea was washing over the vessel and that there was about a foot of water permanently on the deck. At about 1346, the BRIERMIST informed the MCTS centre that she was experiencing pumping problems and was taking on some water in the hold. The master also believed that the afterpeak was full of water and that the pump was not able to cope. The master indicated that there was no water in the engine-room. The MCTS Marine Traffic Regulator (MTR) then asked him for his position. The master gave the following coordinates: latitude 4828.29' N, longitude 06846.81' W. The MTR then asked him if he expected to be able to reach Rimouski on his own. The master replied in the affirmative, adding that he expected to reach the south shore with a great deal of water in the hold. He also stated that he did not have engine problems for the moment, and added that the fish hold pump was operating, but he did not know whether it was capable of keeping the vessel afloat. At about 1348, he indicated that the vessel was making way at four knots and was 10.76 M from Rimouski. The MTR asked the BRIERMIST to stand by and call him back if there was any change. He then asked how many persons were on board. The master replied that there were five persons on board. At about 1349, the MCTS centre contacted the BRIERMIST to ask the master to call every 30 minutes to monitor the situation. At about 1352, the MCTS centre contacted the Qubec Marine Rescue Sub-Centre (MRSC) to inform it of the status and position of the BRIERMIST. The MRSC requested details on the life-saving equipment on board and mentioned thinking about activating the alert system to go to the rescue. At 1355, the MCTS centre contacted the BRIERMIST and asked the master to list the life-saving equipment available to him if they had to abandon the vessel. The master replied that he had a liferaft; then the conversation was cut off. The master subsequently said that the crew members were having a fair amount of difficulty, and that they would be launching the liferaft. Communication then became difficult. The MCTS centre asked whether they would be able to reach Rimouski in those conditions. The master replied that it was not going any better. At 1357, the MCTS centre asked whether there was a cellular telephone on board. The master replied that there was, and that he would go and get it. The MCTS centre asked for the telephone number. The master only had time to give the first digit [7], and the communication was cut off again. After 1358, all attempts to contact the vessel were unsuccessful. Further attempts at about 1413 were also unsuccessful. At 1409, the MCTS centre informed the MRSC that the BRIERMIST was no longer responding to calls. At 1410, a search and rescue (SAR) operation was initiated. 1.3 Search and Rescue (SAR) Operations On November 27 at about 1352, the MCTS centre informed the Qubec MRSC that the BRIERMIST had water in the hold and that the pump was no longer coping. At 1400, a call was made to have a Fisheries and Oceans craft stand by at Sainte-Flavie or Rimouski. At about 1413, the Rimouski Fire Department was alerted and asked to prepare a rigid inflatable rescue craft. At 1416, the MCTS centre broadcast a PAN PAN. At 1417, air support was requested from the Halifax Rescue Coordination Centre (RCC). At 1420, the MCTS centre asked the vessel MENOMINEE, which was in the area east of le du Bic, if she could see anything offshore or detect something on radar to the east of her position. At 1422, the MENOMINEE reported that no fishing vessel could be seen in the area. At about 1425, the MCTS centre broadcast a MAYDAY RELAY and asked vessels in the area to head for the presumed position of the sinking. At 1426, the CANADIAN MINER headed for the last known position of the BRIERMIST. At about 1428, a Hercules aircraft from Canadian Forces Base Greenwood and a Griffon helicopter from the Bagotville base were assigned to the mission. The CCGS GEORGE R. PEARKES, which was in Sept-les, was also assigned to this mission. On November 28 at 1116, the body of one of the victims was recovered; at 1144, the body of a second victim was recovered. Over the three-day search, CCG ships, SAR aircraft and four merchant vessels combed an area of about 50 km2. During this period, two lifebuoys, one floater jacket and other debris from the BRIERMIST were recovered. Despite the efforts of a number of search units to locate the other three victims, the search was unsuccessful. The intensive search was called off on November 29 at 1700. On 02 December 1998, the TSB attempted to locate the wreck of the BRIERMIST using the CALANUS II, a Fisheries and Oceans oceanographic research vessel. Despite two days of searching using sophisticated sonar equipment, no trace of the wreck was found in the area combed. The search covered a rectangular area centred on the probable route of the lost vessel from 4.5 M north-east of le du Bic. 1.4 Injuries to Persons Of the five persons on board, only two bodies were recovered; the others have been declared missing and are presumed drowned. 1.5 Damage 1.5.1 Damage to the Vessel The vessel is presumed to have sunk approximately 4.5 M north-east of le du Bic and about 10 M from Rimouski. In two days of underwater searching for the BRIERMIST, the wreck could not be found. Before the sinking, the master did not indicate whether there was any damage to either the hull or the structure of the vessel. 1.5.2 Damage to the Environment At the time of the sinking, the vessel contained diesel fuel. No trace of oil was found on the water or along the shoreline. 1.6 Certification 1.6.1 Certification of the Vessel and Inspections Under existing regulations, the BRIERMIST had to be inspected every four years. Since she was built in 1981, the vessel had undergone five regular inspections[4] by Transport Canada Marine Safety (TCMS) in Yarmouth, N.S. At the last inspection on 08 August 1997, a ship inspection certificate (SIC 29) was issued to the vessel. The certificate was valid for coastal navigation Class III voyages in Nova Scotia, with a distance of not more than 20 miles from shore. This was a short-term certificate; the original expiry date was 29 October 1997, but it had been extended to 08 August 2001. The certificate indicates that the vessel could not be used to fish for herring or capelin unless the stability data were approved in advance. The inspection report indicates that the condition of the hull and deck was satisfactory. A marine surveyor also had inspected the vessel at Digby, N.S., for insurance purposes. According to the inspection report issued on 17 February 1998, the hull was above average and the maintenance was average. The report does not mention any shortcomings in the vessel's seaworthiness. Because the fishing vessel owner had not requested financial assistance from the ministre de l'Agriculture, des Pches et de l'Alimentation du Qubec (MAPAQ) after his vessel was put in service in the Laurentian region, the MAPAQ had not inspected the vessel. 1.6.2 Personnel Certification To date, any vessel under 70 gross tons is not required by the Canada Shipping Act (CSA) to carry certified personnel on board. However, the master of the BRIERMIST held a Class IV fishing vessel master's certificate issued by Transport Canada (TC) in 1986. None of the four other crew members was certificated. Under the regulations, the seamen were not required to hold certificates or take training. 1.7 Personnel History 1.7.1 Master The master of the BRIERMIST began fishing in 1980. He learned his trade from an experienced fisherman in the region. In 1986, he attended the Centre spcialis des pches in Grande-Rivire, Que., where he took courses in marine chart work and navigation, first aid, shiphandling and seamanship, marine emergency duties (MED) and radio communications. He passed the TC examinations and obtained his certificate as fishing vessel master Class IV in 1986. From 1987 to 1990, he owned the 12 m fishing vessel LE CAYEN (official number 346262) and then a 13 m wooden trawler, the DAWN H., fitted to fish groundfish and scallops. Because the DAWN H. was extensively damaged in the fall of 1997, the master purchased the BRIERMIST in February 1998 from a fishing company in Westport on Brier Island, N.S. This was the vessel's first fishing season in area 16A in the estuary of the St. Lawrence River. 1.7.2 Crew Members None of the other four crew members on board the BRIERMIST had taken MED training, and none had attended the Centre spcialis des pches, which gives training to fishermen. The experience of the seamen on board the vessel was limited to working as fisherman's helpers for a few seasons on fishing vessels in the region. In the case of the youngest, it was his first trip to sea. 1.8 Weather Conditions and Current Information 1.8.1 Weather Forecasts The CCG radio station was broadcasting weather bulletins continually. The weather bulletins for the area from Tadoussac to Pointe-des-Monts, Que., issued by Environment Canada at 1530 on Friday, 27 November 1998, indicated the following conditions: Gale warning in effect (. . .) Winds north-west 25 to 35 knots this evening. Visibility fair to poor under snow flurries. Low -4C, high 2C. 1.8.2 Weather Reported by the Master of the Vessel At 1349, when the MTR contacted the master of the BRIERMIST, he asked about the wind speed in the area of the vessel and whether the winds were still from the east. The master replied: east wind, possibly about 20 to 25 knots. However, when the CANADIAN MINER reached the presumed position of the sinking at about 1430, she reported that the wind was from 345 degrees at 20 knots. According to the MCTS log, the wind had turned from east to north at 0745 that morning. 1.8.3 Weather Recorded by the Nearest Station According to the Environment Canada weather office, the most representative wind observations (speed and direction) for the Les Escoumins-Rimouski area are those from le Rouge, opposite Les Escoumins. The observations indicate that, when the BRIERMIST took shelter at the Les Escoumins pilot station, the wind was north-east at 39 km/h. When she departed on the morning of November 27, the wind had shifted to the north-north-west at 35 km/h, then to the north-west at 39 km/h at 1500. At 1200 on November 27, on le Bicquette, five miles west of the presumed position of the sinking, the wind changed to the north at 43 km/h, then to the north-north-west at 35 km/h at 1400, and finally to the north-west at 22 km/h at 1600. The Les Escoumins pilot boat also recorded strong north-west winds. 1.9 Navigation Equipment 1.9.1 Navigation Instruments The BRIERMIST was equipped with an Internav LC-300 Loran C, interfaced with a Raytheon Rayplot 700L video plotter. She was also equipped with a Micrologic Mariner global positioning system (GPS), a Furuno FR-240 MKII/JMA 301 radar and a Wagner MK IV automatic pilot. 1.9.2 Aids to Navigation There was no report of any malfunction in land-based aids to navigation that could have played a role in the occurrence. 1.10 Radio Communications The BRIERMIST was equipped with two very high frequency (VHF) radiotelephones: a King 7000 and a President MC722. Radio communications reception was loud and clear on departing Les Escoumins. 1.10.1 Marine Communications and Traffic Services (MCTS) Vessel movements in the St. Lawrence River are governed by the Vessel Traffic Services Zones Regulations applicable to the St. Lawrence Seaway between 06600' W and the upstream limit of the Montreal Harbour. Participation in the traffic system is not compulsory for fishing vessels under 24 m and up to a gross tonnage of 150. At 0938 on November 27, the BRIERMIST informed the MCTS of her destination and estimated time of arrival in Rimouski. The MCTS centre asked the master to contact the centre as soon as the vessel had reached her destination. The MCTS centre called the vessel a few times to inquire about the situation on board and to revise the estimated time of arrival. The 1302 and 1349 communications on VHF radiotelephone channel 9 recorded by the MCTS centre show that reception was good. However, the 1355 communication was poor and broken. During that conversation, the master of the BRIERMIST mentioned that he was having difficulties. At no time did the master request assistance. He began giving a number for the cellular telephone on board, but the conversation was cut off before he could finish. No distress call or further communication was received from the BRIERMIST after 1357. 1.11 Mechanical Systems and Bilge Pumping 1.11.1 General Mechanical Information The vessel inspection reports by TC and the insurer indicate that the engine of the BRIERMIST was in good condition. The mechanical difficulties that delayed the start of operations with the vessel in the spring mostly had to do with the hydraulics of the winches on the after deck. 1.11.2 Detection and Pumping Systems The vessel was not equipped with a water level detector in the fish hold, and it was not required to have one. According to the TCMS report, the 38 mm-diameter bilge suctions were located in the forepeak, the engine-room and the fish hold. Pumping was normally initiated from the wheel-house. In an emergency, the auxiliary pump could be started manually. System capacity was 0.3 m3 per minute. According to the report of the marine surveyor hired by the insurer, the bilge pumping system consisted of a pump driven by the main engine and another powered by 32-volt batteries. The afterpeak was not connected to the pumping system, but it had a drainage hole. The insurer's report states that these pumps were not started up during the inspection. 1.12 Emergency Equipment 1.12.1 Life-saving Equipment According to the report of the last inspection, the vessel carried a Class A emergency pack containing 6 type A distress flares and 12 type C hand-held flares. The vessel was equipped with two lifebuoys, one with a light manufactured by McMurdo Marine in 1986 and identified as model L41B with an expiry date of July 2001. A Dunlop-brand six-person inflatable liferaft had last been inspected by TC on 28 July 1997, and was considered in good condition at the time. The raft was located on top of the wheel-house, exposed to the wind and seas, and was held in a cradle by a gripe attached to a senhouse slip hook; this arrangement would require manual release. Existing regulations did not require the liferaft to be equipped with a hydrostatic release unit or any other automatic release device. The raft was not found. Under the EPIRB Regulations, the BRIERMIST, being less than 20 m long, was not required to carry an emergency position indicating radio beacon (EPIRB). 1.12.2 Immersion Suits - Regulatory Requirements The BRIERMIST did not carry any immersion suits, and the Small Fishing Vessel Inspection Regulations did not require that immersion suits be carried on board. However, in accordance with the regulations, there were at least four lifejackets on board, and even though it was not mandatory, the master had also purchased two nose-to-toes personal flotation devices (PFD)[5] [floater suits/worksuits], in addition to the two floater jackets he already owned. These items were usually stored in the wheel-house and the engine-room. One of the two seamen recovered was wearing his own floater suit/worksuit. 1.13 Hatch and Lazaret Covers The fish hold of the BRIERMIST had four circular scuttles approximately 35 cm in diameter and a hold hatch one metre square with a coaming about 40 cm high. To close the fish hold, the main hatch was covered by two fibreglassed wood covers. These covers were simply placed on the coaming flange. There was no watertight seal for the main hatch. Because there was a gap of about 2 cm between the two covers, water could enter the hatch. One of the two covers became dislodged and was found on the shore 100 km downstream of the position of the sinking. Because there was no system for permanently securing or lashing these covers in place, routine practice on board the BRIERMIST was not to secure or cover these panels. Since the vessel was built in 1981, no owner had considered it necessary to install a permanent lashing device for these main hatch covers. TC had not required the two covers to be watertight. The only watertight covers were the four scuttles on the deck. These openings were equipped with watertight seals and covers with locking devices. However, according to the information available, when the crew washed the deck, water entered through the seal in at least one of these scuttles. The lazaret manhole cover was normally kept closed and secured. It was reported that it was difficult to open. After the sinking of the scallop dragger CAPE ASPY in January 1993 (TSB report No. M93M4004), the Board found deficiencies similar to those found during the investigation into the sinking of the NADINE (TSB report No. M90L3034). The TSB recommended that the Department of Transport develop and implement measures to ensure that owners, operators and masters of vessels under its jurisdiction have effective training and procedures for securing all exterior and interior openings sufficient to preserve the watertight integrity of the hull for the environmental conditions being encountered (recommendation M93-01, issued March 1993). TC replied that the importance of watertight integrity and its effects on the vessels' stability would be brought to the attention of the industry by the examiners of masters, mates and engineers by intensifying the examination in these areas. Furthermore, TC issued a Ship Safety Bulletin (SSB) urging mariners and operators to keep watertight openings securely closed at all times, except when it is absolutely necessary to open them to gain access to spaces (SSB No. 16/92). TC also re-circulated SSB Nos. 1/83 and 4/87 on the same subject. Furthermore, the CCG document entitled Small Fishing Vessel Safety Manual (TP 10038) stipulates that crews must keep all watertight closures closed, especially before oncoming heavy weather. SSB No. 06/98, issued 08 April 1998, reminded vessel masters and owners of the importance of carefully closing exterior openings, such as doors, hatches and scuttles, on a vessel. Also, the IMO Code of Safety for Fishermen and Fishing Vessels states, under the heading Safety of the Vessel, that the fittings for closing and securing hatches should be kept in good condition, that all hatches and flush deck scuttles should be closed and properly secured when not in use during fishing, and that, in bad weather, inspections should be made to ensure that hatch covers and lashings are in order. 1.14 Modifications to the Vessel A few months after purchasing the BRIERMIST, the owner made a number of modifications to facilitate fishing from the stern. In April 1998, a plate consisting of a protective metal bar was bolted to starboard, in way of the propeller, to prevent the scallop drag from becoming caught while being hoisted laterally. During the summer of 1998, the owner installed a crane and a net drum he had recovered from his former fishing vessel. In September 1998, 42 ingots of 102 pounds each were added in the bottom forward section of the vessel to compensate for the weight of the net drum and crane on the after deck. Some modifications were completed in Matane, Que., to add weight to the scallop drag. A box of stones that had been stowed in the hold to act as a counterweight for the lateral trawl was removed. Together, these modifications did not change the draught and trim significantly. The CSA requires small fishing vessels to be inspected every four years at which time modifications and/or additional equipment can be inspected by TCMS. The onus to inform TCMS rests with the owner. The Gasp regional office of TCMS did not have a record of these modifications; therefore, no inspector was called upon to certify the vessel from a safety point of view after the modifications or to assess the impact of these changes on the operation of the vessel. There is no notification system between the regional offices of TCMS when ownership of a vessel is transferred from one region of the country to another. Many fishermen and fishing vessel operators apparently do not know that modifications and added equipment can affect a vessel's stability and jeopardize crew safety. In 1994, following its investigation into the sinking of the fishing vessel LE BOUT DE LIGNE in the Gulf of St. Lawrence on 13 December 1990 (TSB report No. M90L3033), the Board recommended that the Department of Transport emphasize, through a safety awareness program for owners, operators and officers of fishing vessels, the adverse effects of structural modifications and additional items on vessel stability (recommendation M94-31, issued December 1994). In recommendation M94-32 (issued December 1994), the Board recommended that means be explored to ensure that structural modifications and the addition of weight items are recorded and accounted for in re-assessing the stability of small fishing vessels.